What is the role of using sodium thiosulfate or bisphosphonates in the treatment for calciphylaxis?

Survival, Risk Factors, and Effect of Treatment in 101 Patients With Calciphylaxis

OBJECTIVE

To report on the survival and the associations of treatments upon survival of patients with calciphylaxis seen at a single center.

PATIENTS AND METHODS

Using the International Classification of Diseases, Ninth Revision diagnosis code of 275.49 and the keyword "calciphylaxis" in the dismissal narrative, we retrospectively identified 101 patients with calciphylaxis seen at our institution between January 1, 1999, through September 20, 2014, using a predefined, consensus-developed classification scheme.

RESULTS

The average age of patients was 60 years: 81 (80.2%) were women; 68 (68.0%) were obese; 19 (18.8%) had stage 0 to 2 chronic kidney disease (CKD), 19 (18.9%) had stage 3 or 4 CKD; 63 (62.4%) had stage 5 or 5D (dialysis) CKD. Seventy-five patients died during follow-up. Six-month survival was 57%. Lack of surgical debridement was associated with insignificantly lower 6-month survival (hazard ratio [HR]=1.99; 95% CI, 0.96-4.15; P=.07) and significantly poorer survival for the entire duration of follow-up (HR=1.98; 95% CI, 1.15-3.41; P=.01), which was most pronounced in stage 5 or 5D CKD (HR=1.91; 95% CI, 1.03-3.56; P=.04). Among patients with stage 5/5D CKD, subtotal parathyroidectomy (performed only in patients with hyperparathyroidism) was associated with better 6-month (HR=0.12; 95% CI, 0.02-0.90; P=.04) and overall survival (HR= 0.37; 95% CI, 0.15-0.87; P=.02).

CONCLUSION

Calciphylaxis is associated with a high mortality rate. Significantly effective treatments included surgical debridement and subtotal parathyroidectomy in patients with stage 5/5D CKD with hyperparathyroidism. Treatments with tissue-plasminogen activator, sodium thiosulfate, and hyperbaric oxygen therapy were not associated with higher mortality.

Sodium thiosulfate is effective in calcific uremic arteriolopathy complicating chronic hemodialysis

BACKGROUND

Calcific uremic arteriolopathy (CUA) or calciphylaxis is a severe complication of advanced chronic kidney disease (CKD) and dialysis. Few effective treatments are available and the mortality rate is high. We report 4 cases in which sodium thiosulfate therapy was rapidly effective.

CASES

Sodium thiosulfate therapy was given to 4 Caucasian patients (3 females and 1 male aged 49 to 91 years) with CUA. The causes of end-stage CKD were nephroangiosclerosis (n=2) and diabetic nephropathy (n=2). The lesions developed 1 to 6.5 years after the initiation of hemodialysis and involved the lower limbs in 2 patients, the fingers in 1 patient, and a breast in the remaining patient. They were responsible for pain and skin necrosis in all 4 patients. Local superinfection occurred in 3 patients. Intravenous sodium thiosulfate was given in a dosage of 12.5 to 25g after each hemodialysis session, for 12 to 24 weeks. The pain and trophic disorders resolved fully in all 4 patients. The side effects consisted of nausea and vomiting (n=2) and a moderate blood pressure decrease (n=1). No recurrences were noted during the follow-up of 5 to 17 months after treatment discontinuation.

CONCLUSION

The findings from this small case-series suggest that sodium thiosulfate may hold promise for the treatment of CUA.

Extraosseous calcification in end-stage renal disease: from visceral organs to vasculature

In earlier days, periarticular accumulations of calcium phosphate causing tumor-like depositions were considered the result of passive precipitation and referred to as metastatic calcifications. From sophisticated computer tomographic studies and growing insight, we have learned that calcifications in the cardiovascular system are far more threatening and in fact one of the most important sequela of end-stage renal disease. The histologic characteristic of uremia-related calcification is arteriosclerosis of the media. In addition, there is atherosclerosis of the intima, due to the high prevalence of classic cardiovascular risk factors in renal disease. The two vascular features can frequently exist at different sites in the vasculature. Novel diagnostic techniques are helping to elucidate the pathogenetic mechanisms of active conversion of vascular smooth muscle cells to osteochondritic cells. Through this process, extensive calcification of the central and peripheral vasculature ensues, influenced by different promotors and inhibitors. Calciphylaxis is a special form of extraosseous calcification leading to skin necrosis. The factors that trigger the development of calciphylaxis are not completely understood, but this syndrome shares part of the pathophysiologic basis of extraosseous calcification in general. However, the therapeutic approach must be prompt and aggressive, because of the poor prognosis. Frequently, a fatal outcome cannot be avoided in calciphylaxis.

Nonuraemic nonfatal idiopathic calciphylaxis in a kitten

BACKGROUND

Calciphylaxis is a rare cutaneous disorder, characterized by vascular calcification and progressive skin necrosis, not yet described in cats. It is scarcely reported in animals, mostly due to iatrogenic or uraemic disturbances of the calcium-phosphate balance. In human patients, it is most commonly seen with end-stage renal disease, but several nonuraemic disorders, including inherited dysfunctions of tissue calcification inhibitors, have also been described.

HYPOTHESIS/OBJECTIVES

To describe a case of nonuraemic calciphylaxis in a cat.

ANIMALS

A 10-week-old male domestic short hair kitten was presented with hyperacute skin lesions. Initial dermatological signs were characterized by sharp demarcated erosions and ulcerations on the face, including the nasal planum and lips. Cutaneous lesions rapidly progressed into thick crusts with ulcerations, involving parts of the face and pinna as well as abdominal skin.

METHODS

Complete blood count, serum chemistry profile, urinalysis, parathyroid hormone measurement and histopathological examination of skin biopsies.

RESULTS

Histopathology from newly developed abdominal skin lesions revealed severe epidermal necrosis and calcification, multifocal pannicular calcification and calcified subcutaneous vessels, supporting a diagnosis of calciphylaxis. Treatment consisted of systemic and topical antimicrobials, analgesics, pentoxifylline, Lantharenol(®) , sodium thiosulfate and vitamin K. After initiation of therapy, no further progression was noticed; all medications could be discontinued eventually, and no relapse was seen in the following 2 years.

CONCLUSIONS AND CLINICAL IMPORTANCE

Calciphylaxis should be considered as a differential diagnosis for ulcerative cutaneous disorders in young cats. More information on this disease is needed to elucidate the pathomechanism.